integrated primary/behavioral health care for those ... · case study: mr. a • mr. a is a ......

Integrated Primary/Behavioral Health Care

For Those Experiencing Homelessness

June 23, 2014 , 2:00 PM ET

Colorado Coalition for the Homeless

Presenters

• Dr. David Otto, Medical Director of “Integrated Health Services at

Colorado Coalition for the Homeless”

• Bette (BJ) Iacino, Vice President, Public Policy and

Communications “Colorado Coalition for the Homeless”

• (APRN, will present case study, waiting for information)

Colorado Coalition for the Homeless (An HCH Provider )

• 30 Years: FQHC & HCH Provider

• 54 Programs & 500+ Staff: Housing, Healthcare & Support

Services (Outreach, Employment Services & Childcare)

• Healthcare @ 8 locations

• Housing @ 18 locations

• Serve 15,000 men, women and children

Colorado Coalition for the Homeless

Integrated Health Services Model

• Developed in 3 Phases:

West End Clinic

Stout Street Clinic

Stout Street Health

Center

• Three Organization

Goals

Integrated Teams

Provider Competencies

Organization Capacity

West End Health Center: Phase One

West End Health Center

EHR is Essential

Behavioral Health Provider (BHP) is

Central to the Model

Behavioral Health Provider (BHP)

• Member of the primary care team

• Main role - identify, consult, treat, triage and manage

primary care patients with behavioral health and/or

medical problems

• Goal is to improve their ability to function.

Who Are BHPs?

• Multiple professions and license types

• Social Workers: LCSW, LSW

• Counselors: LPC

• Registered Psychotherapists: RP

• Doctors of Behavioral Health: DBH

• Psychologists: PhD, PsyD

• Registered Nurses: RN

• Additional specialist in CCH model

• Substance Abuse Counselors: LAC, CAC II, CAC III

Why is BHP Needed in Primary Care for Homeless?

• 50% of mental health care is currently provided in primary care

• 70% of community health patients have mental health and/or substance use disorders

• 70% of all primary care visits have some sort of psychosocial component

• 50-60% of non-adherence to psychoactive medications occur within the first 4 weeks

• One in four patients referred to specialty mental health do not make it to their first appointment

(Strosahl & Robinson, 2009)

Integrated Primary Behavioral Health Care

for the Homeless

• Targeted interventions

• Limited sessions

• Faster pace

• 15-30 minute sessions

• Physician controls

treatment

• Referral based on

presentation

• Confidentiality includes

PCP

• Shared medical record

• Public health approach

• Population-based vs

individual-based

• Functional focus

• Medical and behavioral

health

How can BHPs Assist With Medical Patients

Who Are Experiencing Homelessness?

• Treatment compliance /

medication adherence

• Ambivalence/motivation

enhancement

• Goal setting

• Behavior change plans

• Coping with medical

diagnoses

• Coping with stress

Interventions Utilized:

• Motivational Interviewing

• Cognitive Behavioral

Therapy

• Acceptance and

Commitment Therapy

• Solution-Focused Therapy

• Dialectical Behavioral

Therapy

• Group Therapy

Pilot Project: Stout Street Clinic

Reason for Referral

• Depression – 23

• Psychosis/Schizophrenia – 14

• Bipolar Mood Disorder – 8

• MH Hold Assessment – 6

• Anxiety – 6

• PTSD – 4

• ADD – 1

• Substance Abuse – 1

• Pain – 1

• Transgender Transition Readiness – 1

• School Problems – 1

• Diagnostic Clarification and Resourcing - 1

Audience Poll Question #1 and

Chat Box Questions

Integrated Case Study

Case Study: Mr. A

• Mr. A is a middle aged man who presented to the

Medical Team at our Stout Street Clinic for the first

time, late on a Friday afternoon, this past winter.

• He was psychotic and suffering from severe frostbite

to both his feet.

Mr. A

• Due to his mental illness, he was unable to care for his

feet and was referred to respite.

• Nurses were unable to find a Medical Respite that

would accept him, due to his untreated psychosis, loud

outbursts, and irritability.

• He was referred to a local shelter, but instead

continued to sleep outside on freezing cold nights.

Mr. A

• He was referred to our Mental Health Team by Medical

after observed to be responding to internal stimuli.

• He was evaluated by MH and placed on a Mental

Health Hold for grave disability.

• Unfortunately, the ER discharged him late on a cold

night.

• He continued to sleep outside.

Mr. A

• He was started on Risperidone and his

psychiatric symptoms appeared to improve.

• He was accepted to Medical Respite.

• For multiple weeks, he stayed in respite and

returned for regular foot care.

• He was evaluated by a foot specialist and

scheduled for amputation.

Mr. A

• He stopped taking Risperidone.

• He missed his pre-op appointment and stopped coming in for foot care.

• He returned to the clinic several weeks later, requesting pain management.

• He had been prescribed Tramadol, but took up to 7 tablets at once and ran out. He was prescribed Tylenol with codeine by a covering MD and quickly took the entire bottle.

Mr. A

• It was determined that his infection risk was too great

for outpatient care; he was referred to a local ER

anticipating he might be taken in for emergency

surgery.

• He was not admitted.

• Approximately 1 week later, he was seen in MH and

switched to Abilify, after reporting that the Risperidone

was too sedating.

• He did not follow up in medical and was not seen

again. A nurse heard that he was camping east of

town under a bridge.

Outcomes

• The team met to discuss how we could engage this

gentleman in both medical and mental health care, as

well as move him toward housing and public benefits.

• Mr. A was discussed in the outreach meeting. That

afternoon, an outreach worker found him and Mr. A

informed him that he had an appointment the next day

with surgery at a local hospital. Mr. A was then

transported by outreach and he received wound care.

Outcomes

• Mr. A was placed in a motel with a 2-week voucher in

hopes that he would be willing to come to the clinic

daily for wound care and medication monitoring.

• The PCP ordered Tramadol to be delivered to our

clinic.

• During those daily visits, Mr. A was provided with

wound care, dispensed Tramadol for pain, (1 tab in

clinic and 1 to take with him, 5 to take with him on

Friday).

• He receives a daily dose of Abilify and is encouraged

to consider a long-acting injectable.

Outcomes

• Outreach transports him 4 days/week and he is offered

bus fare when needed.

• RN’s have the greatest alliance with Mr. A and interact

with him at every visit.

• Mental Health staff stop into medical visits and attempt

to engage him.

Outcomes

• We hope he will become familiar with all potential

providers on his team, in order to increase engagement.

• The BHP has contacted Medicaid to establish increased

case management services and to see if he is eligible for

a group home.

• The Patient Navigator is discussing him further with

Respite, in hopes of placing him there until his wounds

heal.

• He has been referred to the Benefits Acquisition Team.

• He has been referred to Supportive Housing.

Audience Poll Question #2 and

Chat Box Questions

Grantee Perspective Presenters

DESC

Downtown Emergency Services Center

Seattle, WA

Christina Clayton, LICSW, CDP - Clinical Program Manager (DESC)

Lisa Johnson, ARNP (HMC)

Lew Middleton, Peer Specialist (DESC)

www.desc.org

• Agency mission

• Program description

• Considerations

• Strategies

• Findings

• Lessons learned

Outline

Overview of DESC • Emergency shelter

• Drop-in/Day Services

• Licensed mental health

• Licensed chemical

dependency

• Supported Employment

• Crisis Diversion

• Permanent Supportive

housing

• High level of integration

across programs

www.desc.org

Core Convictions

• Housing is a basic human right,

not a reward for clinical

success or compliance.

• Once the chaos of

homelessness is eliminated

from a person’s life, clinical and

social stabilization occur faster

and are more enduring.

www.desc.org

Homelessness is still a crisis…

King County

• More than 2 million residents (14th most populous in U.S.)

One Night Count in King County:

• January 24, 2014—800+ volunteers

• 3,123 living outside

• 2,906 in emergency shelters

• 3,265 in transitional housing

TOTAL = 9,294

Estimate 20% meet chronic homelessness

criteria (1,858)

• Primary care clinics co-located in two sites in downtown Seattle: • Downtown Emergency Service Center (DESC), • Harborview Mental Health & Addiction Services (HMHAS)

• Both sites serve high need urban population, high percent: • Experiencing homelessness, including chronic homelessness • With co-occurring substance use issues

• Target populations • Year 1 focus: Individuals with diagnosis of psychotic disorder, taking

atypical antipsychotic medication; no regular source of primary care • Current focus: Anyone served by either clinic who is not connected or

poorly connected with primary care.

Our Program

• Advanced Registered Nurse Practitioner (ARNP)

• Nurse Care Coordinator (RN)

• Peer Specialist

• Behavioral Health Staff: Case Managers, Nurses, Psychiatric Providers, Peers, Employment, Substance Use staff, Drop-in staff, Shelter and Housing staff

Our Team

Role of Primary Care Partner

• Mission and Core Values

• History of Partnership

• Location & Logistics

• Services Provided

• Aligning Approach

• Collaboration with Teams

People We

Serve

10% 6% 8%

41%

76%

58%

49%

18%

34%

0%

20%

40%

60%

80%

100%

DESC (N = 402) HMHAS (N = 381) OVERALL (N = 783)

PE

RC

EN

T

SITE

PBHCI: HOUSING STATUS AT BASELINE BY SITE AS OF 05/23/2014, N =783

NO INFORMATION NOT HOMELESS HOMELESS

1% 2% 3%

24% 24%

1%

40%

11%

1% 2% 3%

26%

17%

1%

48%

7%

0%

20%

40%

60%

80%

100%

ALASKA NATIVE

AMERICAN INDIAN

ASIAN BLACK OR AFRICAN

AMERICAN

MULTIRACIAL NATIVE HAWAIIAN OR

OTHER PACIFIC

ISLANDER

WHITE HISPANIC

PE

RC

EN

T

RACE AND ETHNICITY

PBHCI: RACE AND ETHNICITY BY HOUSING STATUS AS OF 05/23/2014 N = 722

HOMELESS ( N = 268) NOT HOMELESS (N = 454)

73%

26%

1%

64%

35%

1% 0%

20%

40%

60%

80%

100%

MALE FEMALE TRANSGENDER/ OTHER

PE

RC

EN

T

GENDER

PBHCI: GENDER BY HOUSING STATUS AS OF 5/23/2014, N = 722

HOMELESS (N = 268) NOT HOMELESS (N = 454)

8%

8%

15%

19%

38%

15%

21%

19%

26%

21%

0% 20% 40% 60% 80% 100%

ANXIETY

PSYCHOSIS NOS

SCHIZOAFFECTIVE

DEPRESSION

SCHIZOPHRENIA

PERCENT

PBHCI: MENTAL HEALTH DIAGNOSES BY HOUSING STATUS AS OF 05/23/2014, N = 722

HOMELESS ( N = 268) NOT HOMELESS (N = 454)

38%

53%

19%

11%

36%

64%

29% 21%

0%

20%

40%

60%

80%

100%

HYPERTENSION OBESITY ELEVATED HGBA1C

ELEVATED LDL

PE

RC

EN

T

HEALTH OUTCOMES

PBHCI: % OF CLIENTS AT-RISK FOR SELECTED HEALTH OUTCOMES AT BASELINE BY HOUSING STATUS AS OF 5/23/2014, N = 722

HOMELESS (N = 268) NOT HOMELESS (N = 454)

Common Integrated Health Care Issues and Concerns

Acute

Homelessness Chronic

Impact of Homelessness on Care

Impact of Homelessness on Care

Interaction of

PC & BH

Poverty Realities of

Environment Health coverage, access & services

Trauma Severity of Issues

Challenges for:

people served, staff, system

• Fear & Stigma

• Understanding Motivation

• Health and Cultural Literacy

• Feeling Anxious & Overwhelmed

• Health Care Reform

A Journey Towards

Recovery

Engage

Basic Needs

Dignity and Respect

Outreach

Peer Services

Educate

Access to Resources

Familiarity with Staff

Relevant Approaches

Empower

Wellness Activities

Consumer Advisory Board

Whole Health Approach

Harm Reduction & Motivational Interviewing

Advocacy

Strategies to Meet Grant Requirements

• Introduction & Engagement

• Patient Enrollment

• Collecting Data & Follow Up Measures

• Referral to Specialty Care and Completion

Team Building

• Review of data collection/analysis, goals of grant • Discuss successes and challenges • Share learning from webinars, other TA, workshops • Collect information to help with reports • Hold quarterly GPO conference calls with team • Host visitors from other local grantee sites • Dialogue and problem-solve from all levels • Hear stories from those doing the direct work

Ideas to Help Manage “No Show” Concerns

Flexibility

Partnership

Preparation

Evaluate

31%

42% 38%

0%

20%

40%

60%

80%

100%

HOMELESS ( N = 42) NOT HOMELESS (N = 101) OVERALL (N = 143)

% I

MP

RO

VE

D

HOUSING STATUS

CLIENTS WITH HYPERTENSION AT BASELINE AS OF 5/23/2014, N = 143 : PERCENT IMPROVED AT MOST RECENT REASSESSMENT BY HOUSING STATUS

PLEASE NOTE: HYPERTENSION REFERS TO SYSTOLIC BP ≥ 130 MMHG AND/OR DIASTOLIC BP ≥ 85MMHG

13% 7% 8%

0%

20%

40%

60%

80%

100%

HOMELESS ( N = 53) NOT HOMELESS (N = 179) OVERALL (N = 232)

% I

MP

RO

VE

D

HOUSING STATUS

OBESE CLIENTS AT BASELINE AS OF 5/23/2014, N = 232 : PERCENT IMPROVED AT MOST RECENT REASSESSMENT BY HOUSING STATUS

PLEASE NOTE: OBESITY REFERS TO A BMI ≥ 25 K/M2

48%

32% 39%

33%

0%

20%

40%

60%

80%

100%

HOMELESS CLIENTS ( N = 113) ALL CLIENTS (N = 414)

PERCENT OF CLIENTS USING ILLEGAL SUBSTANCES

POSITIVE AT BASELINE POSITIVE AT SECOND INTERVIEW

0%

61%

51%

76%

0%

20%

40%

60%

80%

100%


PERCENT OF CLIENTS WITH A STABLE PLACE TO LIVE


25%

42% 47%

58%

0%

20%

40%

60%

80%

100%


PERCENT OF CLIENTS FUNCTIONING IN EVERYDAY LIFE


57%

74% 74% 80%

0%

20%

40%

60%

80%

100%


PERCENT OF CLIENTS WITHOUT SERIOUS PSYCHOLOGICAL DISTRESS


Lessons Learned

• Understand the Issues

• Approach Care Delivery with Respect

• See the big picture

Scenarios

Final Questions

Website for Resources,

Presenter Photos/Bios,

Webinar Slides and Recording

Special Thanks to Our Presenters!

Colorado Coalition for the

Homeless (Denver, CO)

• David Ott, MD/MBA Medical

Director of Integrated Health

Services

• Dr. Marilyn Smith,

Psychiatrist

Downtown Emergency

Services Center, (Seattle, WA)

• Christina N. Clayton, LICSW,

CDP, PBHCI Project

Coordinator

• Lisa Johnson ARNP, PBHCI

Primary Care Provider

• Lew Middleton, PBHCI Peer

Specialist

integrated primary/behavioral health care for those ... · case study: mr. a • mr. a is a ......

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